Nonelection of Workers' Compensation or Employers' Liability Coverage

Primary tabs

Secondary tabs

Showing 2151 - 2200 of 2227. Show 10 | 50 | 100 | 200 | 500 | 1000 | All results per page.

#	Submitted	User	IP address	Name of Employer:	Type of Entity:	Address of Employer's Home Office:	Statement 1 Agreement:	Statement 2 Agreement:	Statement 3 Agreement:	Understanding Confirmation:	Check Either Alternative (1) or (2):	Date:	Full Name of Individual:	Email:	City of Residence:	County of Residence:	State of Residence:	Full Name of Witness 1:	Full Name of Witness 2:	Signing Indication:	Check either alternative (1) or (2):	Full Name of Authorized Agent:	Email of Authorized Agent:	Relationship to Employer of Authorized Agent:	City of Residence:	County of Residence:	State of Residence:	Full Name of Witness No. 1:	Full Name of Witness No. 2:	Signing Indication:
892	2022-02-03 15:52	Anonymous (not verified)	204.155.61.217	JD DRYWALL	Proprietorship	503 9th Street Kalona, Iowa 52247	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-03	John Duwa	johnduwa@outlook.com	Kalona	Washington	Iowa	Jeff Spenner	Angela Stutzman	Signed	(1) The employer does not elect the employers’ liability coverage.	JD Drywall - John Duwa	johnduwa@outlook.com	owner	Kalona	Washington	Iowa	Jeff Spenner	Angela Stutzman	Signed
1835	2023-09-09 15:11	Anonymous (not verified)	94.188.207.224	Heartland Ultrasonography Group	Limited Liability Company	1015 Woodland Dr Carlisle, IA 50047	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-09	Micah Ezra Wiele	mewiele99@gmail.com	Ankeny	Polk	Iowa	Nathan Miguel Diaz	Brandon Allen Pemoulie	Signed	(1) The employer does not elect the employers’ liability coverage.	Micah Ezra Wiele	heartlandusgroup@outlook.com	Co-owner	Ankeny	Polk	Iowa	Nathan Miguel Diaz	Brandon Allen Pemoulie	Signed
797	2021-12-15 08:01	Anonymous (not verified)	173.22.84.26	LAMPE APPLIANCE SERVICE, Inc	Proprietorship	210 29TH ST NE	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-15	Kenneth Roman Lampe	lampeappliance@gmail.com	CEDAR RAPIDS	Linn	IA	Douglas James Lampe	John Kenneth Lampe	Signed	(1) The employer does not elect the employers’ liability coverage.	Douglas James Lampe	lampeappliance@gmail.com	Vice President	CEDAR RAPIDS	Linn	Iowa	Douglas James Lampe	John Kenneth Lampe	Signed
1004	2022-03-23 15:01	Anonymous (not verified)	104.201.110.2	Ryan Fischer	Proprietorship	809 8th St Sw	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-23	Ryan Fischer	rfischer@phillipsstaffod.com	Des Moines	Polk	IA	Josh Stafford	Desiree Dennis	Signed	(1) The employer does not elect the employers’ liability coverage.	Ryan Fischer	rfischer@phillipsstafford.com	Self	DES MOINES	IA	United States	Josh Stafford	Desiree Dennis	Signed
1947	2023-12-07 16:01	Anonymous (not verified)	94.188.205.176	Reinier Construction LLC	Limited Liability Company	1406 Linden Lane	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-07	David J Reinier	reinierconst@aol.com	Des Moines	Polk	IA	PEGGY A ROHDE	Douglas E Rohde	Signed	(1) The employer does not elect the employers’ liability coverage.	PEGGY A ROHDE	dnprohde@msn.com	Bookkeeper	Polk City	Polk	IA	Douglas E Rohde	Stacie L Miller	Signed
1116	2022-05-17 21:41	Anonymous (not verified)	75.162.182.172	Hinds Metal Designs LLC	Limited Liability Company	11409 Dakota St, Norwalk, IA 50211	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-18	Brad Hinds	bahinds@msn.com	Norwalk	Iowa	Iowa	Trevor Masten	Travis Masten	Signed	(1) The employer does not elect the employers’ liability coverage.	Carlene Hinds	carlene4082@msn.com	Self	Norwalk	Iowa	Iowa	Trevor Masten	Travis Masten	Signed
2059	2024-02-27 11:44	Anonymous (not verified)	94.188.205.169	Dowdey Construction LLC	Limited Liability Company	1010 19th Ave - Rock Valley, IA 51247	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-02-27	Nicholas Allen Dowdey	nddowdey@hotmail.com	Rock Valley	Sioux	Iowa	Deidre Dawn Dowdey	Alexander C Koedam	Signed	(1) The employer does not elect the employers’ liability coverage.	Nicholas Allen Dowdey	nddowdey@hotmail.com	Self	Rock Valley	Sioux	Iowa	Deidre Dawn Dowdey	Alexander C Koedam	Signed
1228	2022-07-26 10:06	Anonymous (not verified)	173.23.93.3	Gaytan Framing LLC	Limited Liability Company	2418 East 37th Court	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-07-26	Jose Gaytan	jose1988.jg8@gmail.com	Des Moines	Polk	United States	CARLA C. GAYTAN	Juan Franco	Signed	(1) The employer does not elect the employers’ liability coverage.	Jose Gaytan	jose1988.jg8@gmail.com	self	Des Moines	IA	United States	CARLA C. GAYTAN	Juan franco	Signed
2171	2024-04-22 14:09	Anonymous (not verified)	94.188.205.176	Messer's concrete cutting	Proprietorship	714 Summer Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-22	Joe messer	josephdmesser@gmail.com	Burlington	IA	United States	Joe messer	Joe messer	Signed	(1) The employer does not elect the employers’ liability coverage.	Joe messer	josephdmesser@gmail.com	Owner	Burlington	IA	United States	Joe messer	Joe messer	Signed
1340	2022-10-18 17:03	Anonymous (not verified)	166.181.89.97	Stevens mobile welding services LLC	Limited Liability Company	5645 se 56th st. Carlisle, IA 50047	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-10-18	Daniel Robert Stephens	dannystephens303@gmail.com	Carlisle	Polk	Iowa	Nikita Marie Knapp	Stacy Robin Stephens	Signed	(1) The employer does not elect the employers’ liability coverage.	Daniel Robert Stephens	dannystephens303@gmail.com	Owner	Carlisle	Polk	Iowa	Nikita Marie Knapp	Stacy Robin Stephens	Signed
1452	2023-02-13 16:49	Anonymous (not verified)	94.188.207.228	The Wine Shop, LLC	Limited Liability Company	305 Main St, Cedar Falls, IA 50613	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2023-02-13	Dana Swasand	danaswasand@rocketmail.com	Steamboat Rock	Hardin Co.	Iowa	Jay Schares	Nicole Erickson	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Dana Swasand	danaswasand@rocketmail.com	Owner/Member	Steamboat Rock	Hardin Co.	Iowa	Jay Schares	Nicole Erickson	Signed
29	2020-01-06 13:44	Anonymous (not verified)	108.178.203.226	MULLIS CATTLE LLC	Limited Liability Company	2506 155TH ST, EARLVILLE IA 52041	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-06	DAVID MULLIS	JAMES@CIOIA.COM	EARLVILLE	DELAWARE	IOWA	MERRI MOSER	BRITTANY LANSING	Signed	(1) The employer does not elect the employers’ liability coverage.	DAVID MULLIS	JAMES@CIOIA.COM	OWNER	EARLVILLE	DELAWARE	IOWA	MERRI MOSER	BRITTANY LANSING	Signed
1564	2023-04-11 09:15	Anonymous (not verified)	94.188.205.174	Darryl Kinnard	Proprietorship	60 Miller Avenue Southwest #13, Cedar Rapids, IA 52404, United States	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-11	Darryl Kinnard	darryl186d@icloud.com	Cedar Rapids	Linn County	Iowa	Jordan Nisiewicz	Jordan Loyd	Signed	(1) The employer does not elect the employers’ liability coverage.	Jordan Nisiewicz	jnisiewicz@leafhome.com	Recruiter	Kansas City	Clay	Missouri	Jordan Loyd	Robert Snyder	Signed
141	2020-04-28 10:14	Anonymous (not verified)	74.84.101.138	Lutheran Cemetery Association	Proprietorship	410 S. Mechanic Street Decorah, IA 52101	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-03-02	Steven Matter	chelsea.whalen@upperiowains.com	Decorah	Winneshiek	IA	Bobbi Jo Berg	Robin C Schultz	Signed	(1) The employer does not elect the employers’ liability coverage.	Steven Matter	chelsea.whalen@upperiowains.com	Secretary	Decorah	Winneshiek	IA	BOBBI JO BERG	Robin C Schultz	Signed
1676	2023-06-02 09:41	Anonymous (not verified)	94.188.207.229	Kacena Family Tree Farm Inc	Partnership	2510 55th St., Vinton, IA 52349	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-01	Debra Kacena	kacenafarms.alyce@gmail.com	Vinton	Benton	Iowa	Ashlyn J. Christianson	Angie McFarland	Signed	(1) The employer does not elect the employers’ liability coverage.	Alyce Lynch	ashlyn@3riversins.net	25% Owners - President	Vinton	Benton	Iowa	Ashlyn J. Christianson	Angie McFarland	Signed
253	2020-09-09 12:27	Anonymous (not verified)	173.18.16.129	H E Drywall INC	Proprietorship	200 E Lally St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-09	Eriberto Castro	hedrywall82@gmail.com	Des Moines	Polk	Iowa	Lesa Reeves	Jake Hibbert	Signed	(1) The employer does not elect the employers’ liability coverage.	eriberto castro	hedrywall82@gmail.com	owner	Des Moines	Polk	Iowa	Lesa Reeves	Jake Hibbert	Signed
365	2021-01-15 11:24	Anonymous (not verified)	63.227.74.126	Paramount Kitchen and Bath	Limited Liability Company	2155 SE 37TH ST STE C	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-01-15	Michael Simpson	mike@paramount-kitchens.com	GRIMES	Iowa	United States	Cory Morris	Jason Andersen	Signed	(1) The employer does not elect the employers’ liability coverage.	Michael Simpson	mike@paramount-kitchens.com	Owner	GRIMES	Iowa	United States	Cory Morris	Jason Andersen	Signed
477	2021-04-14 11:04	Anonymous (not verified)	65.103.82.36	Lisa Kuhn	Proprietorship	427 s Concord Davenport IA 52802	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-09	Lisa Kuhn	none@hotmail.com	davenport	Scott	IA	Sarah	Erick	Signed	(1) The employer does not elect the employers’ liability coverage.	Lisa Kuhn	none@hotmail.com	self	davenport	scott	IA	sarah	erick	Signed
589	2021-07-28 16:09	Anonymous (not verified)	97.125.35.240	Sotero Alonso Calderon Velasquez	Proprietorship	1312 Idaho St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-07-26	Sotero Alonso Calderon Velazquez	deb@piciowa.com	Des Moines	Polk	Iowa	Debra Stratton	Martin Pinon	Signed	(1) The employer does not elect the employers’ liability coverage.	Sotero Alonso Calderon Velazquez	deb@piciowa.com	subcontractor	Des MOines	Polk	Iowa	Debra Stratton	Martin Pinon	Signed
701	2021-10-29 18:35	Anonymous (not verified)	173.18.85.215	Saunders Construction	Proprietorship	7304 SW 14th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-10-29	Charles Saunders	charlessaunders901@gmail.com	Des Moines	Iowa	Iowa	Ramona Mitchell	Rasheedah Gasaway	Signed	(1) The employer does not elect the employers’ liability coverage.	Charles Saunders	charlessaunders901@gmail.com	Owner	Des Moines	IA	United States	Ramona Mitchell	Rasheedah Gasaway	Signed
908	2022-02-09 15:06	Anonymous (not verified)	63.152.66.183	Shear Texture	Limited Liability Company	1427 A Ave NW	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-09	Wendy Kiser	kiser187@msn.com	Cedar Rapids	Linn	Iowa	Shelly Wehr	Kimberly Erickson	Signed	(1) The employer does not elect the employers’ liability coverage.	Wendy Kiser	kiser187@msn.com	Self	Cedar Rapids	Linn	Iowa	Shelly Wehr	Kimberly Erickson	Signed
1851	2023-09-22 12:36	Anonymous (not verified)	94.188.207.229	MNM Construction	Proprietorship	3224 sw 12th place des moines iowa 50315	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-09-22	craig allen mccormick	craigmccormick.6363@gmail.com	Des Moines	Iowa	Iowa	Tara Murphy	Kristie Hubbard	Signed	(1) The employer does not elect the employers’ liability coverage.	craig mccormick	craigmccormick.6363@gmail.com	self	Des Moines	Iowa	Iowa	Tara Murphy	Kristie Hubbard	Signed
813	2021-12-27 10:18	Anonymous (not verified)	172.58.84.252	LLC	Partnership	866 40th Ave Bettendorf, IA	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-12-23	Kimberly Anne Liggitt	kliggitt25@gmail.com	Rock Island	IL	United States	Suzanne Jeanette Liggitt	Christie Marie Liggitt	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody Dunbar	codydunbar@leaffilter.com	Manager	866 40th Ave Bettendorf ia 52722	Scott County	IA	Jordan nisiewicz	Cody Dunbar	Signed
1020	2022-03-29 16:53	Anonymous (not verified)	207.32.60.144	J.A. Dahlhauser, Ltd.	Proprietorship	1741 Hwy. 7	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-03-29	Jaylin A. Dahlhauser	jaydahlhauser@gmail.com	Newell	IA	United States	Matthew McClellan	Gracelin R. Dahlhauser	Signed	(1) The employer does not elect the employers’ liability coverage.	Jaylin A. DAhlhauser	jaydahlhauser@gmail.com	Owner	Newell	IA	United States	Matthew McClellan	Gracelin R. Dahlhauser	Signed
1963	2023-12-18 14:45	Anonymous (not verified)	94.188.207.227	Elite Excavation Services	Limited Liability Company	13335 Amber Rd X44 Anamosa Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-12-18	Dalton Starn	eliteexcavationservices97@gmail.com	Anamosa	Jones	Iowa	Chase miller	Nathan Decker	Signed	(1) The employer does not elect the employers’ liability coverage.	Dalton Starn	eliteexcavationservices97@gmail.com	Owner	Anamosa	Jones	Iowa	Chase miller	Nathan decker	Signed
1132	2022-05-28 12:01	Anonymous (not verified)	166.181.81.175	Kamp Trucking LLC	Limited Liability Company	3411 doris lane	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-05-28	Joseph Michael Kamp	boss4z9@yahoo.com	waterloo	Iowa	United States	Glenn Harrison Bearbower	April Ann Bearbower	Signed	(1) The employer does not elect the employers’ liability coverage.	Joseph Michael Kamp	boss4z9@yahoo.com	same person. I am an owner operator	waterloo	Iowa	United States	Glenn Harrison Bearbower	April Ann Bearbower	Signed
2075	2024-03-05 22:32	Anonymous (not verified)	94.188.207.225	Steve Roland Trucking LLC	Limited Liability Company	2141 Wadsley Avenue	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-05	Steve Roland	roland.farms@yahoo.com	Sac City	IA	United States	Caylee Hoffard	Kristen Wirtjers	Signed	(1) The employer does not elect the employers’ liability coverage.	Steve Roland	roland.farms@yahoo.com	Owner/Member	Sac City	IA	United States	Caylee Hoffard	Kristen Wirtjers	Signed
1244	2022-08-08 09:28	Anonymous (not verified)	174.255.1.240	Jose Rivera	Proprietorship	6100 w lincoln way lot 25 Ames lA 50014	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-08-08	Jose Rivera	josechepe91@icloud.com	Ames	Boone	lowa	Jose Rivera	Jose Rivera	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Tim	Tim@thefortress.net	Friends	Ames	Boone	Iowa	Eliazar Martinez	Sabino Díaz	Signed
2187	2024-04-29 08:30	Anonymous (not verified)	94.188.207.226	Fran Stonework LLC	Limited Liability Company	1222 E Seneca Ave Apt 7, Des Moines, IA 50316	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-04-29	Francisco Rodriguez Rios	panchito941@icloud.com	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Francisco Rodriguez Rios	panchito941@icloud.com	Self	Des Moines	Polk	Iowa	Fabiola Palomares	Nathan Miller	Signed
1356	2022-11-02 08:21	Anonymous (not verified)	174.215.249.84	Leaf home solutions	Proprietorship	1595 Georgetown Road, Hudson, OH 44236	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-02	Micheal Wills	mwills5304@gmail.com	Granger	Polk	IA	Bryanna Wills	Andrew Vannausdle	Signed	(1) The employer does not elect the employers’ liability coverage.	Bryanna Wills	bryannawills725@gmail.com	None	Granger	Polk	IA	Andrew Vannausdle	Micheal Wills	Signed
1468	2023-02-17 16:17	Anonymous (not verified)	94.188.207.230	AJ Cook LLC	Limited Liability Company	1817 Redbud Street, Norwalk, IA 50211	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-02-17	Alejandro Cook	alejandro.cook14@gmail.com	Norwalk	Warren	Iowa	Steve Bieghler	Nichole Bishop	Signed	(1) The employer does not elect the employers’ liability coverage.	Alejandro Cook	alejandro.cook14@gmail.com	Self	Norwalk	Warren	Iowa	Steve Bieghler	Nichole Bishop	Signed
45	2020-01-28 16:13	Anonymous (not verified)	173.18.3.76	Delic Marble and Tile LLC	Limited Liability Company	24 Ellefson Dr PO Box 413 DeSoto, IA 50069	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-01-31	Adin Delic	delicgraniteandtile@gmail.com	Adel	Dallas	Iowa	Angela Kinsey	Taylor Benshoof	Signed	(1) The employer does not elect the employers’ liability coverage.	Lutfija Delic	delicgraniteandtile@gmail.com	LLC Member	Adel	Dallas	Iowa	Angela Kinsey	Taylor Benshoof	Signed
1580	2023-04-17 20:22	Anonymous (not verified)	94.188.205.167	Lance Van Der weerd	Limited Liability Company	909 S Adams Street Rock Rapids IA 51246	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-04-17	Lance Van Der Weerd	enterprisesvdw@gmail.com	Rock Rapids	IA	United States	Brittany Van Der Weerd	Todd Mienerts	Signed	(1) The employer does not elect the employers’ liability coverage.	Lance Van Der Weerd	enterprisesvdw@gmail.com	Myself	Rock Rapids	Lyon	Iowa	Brittany Van Der Weerd	Todd Mienerts	Signed
157	2020-05-14 15:11	Anonymous (not verified)	173.28.28.57	Brett Dix	Proprietorship	16696 245th Street, Aplington, IA 50604	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-04-30	Brett Dix	cmins_re@mchsi.com	Aplington	Butler	IA	Chad Campbell	Roxanne Kolder	Signed	(1) The employer does not elect the employers’ liability coverage.	Brett Dix	cmins_re@mchsi.com	Self	Aplington	Butler	IA	Chad Campbell	Roxanne Kolder	Signed
1692	2023-06-15 15:20	Anonymous (not verified)	94.188.207.228	Javier Rodriguez	Proprietorship	1512 18th St Des Moines, Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-06-14	Javier A Rodriguez	R.Javier14@gmail.com	Des Moines	Polk	Iowa	Kelly Denger	Debra Stratton	Signed	(1) The employer does not elect the employers’ liability coverage.	Javier A Rodriguez	R.Javier14@gmail.com	self	Des Moines	Polk	Iowa	Kelly Denger	Debra Stratton	Signed
269	2020-09-23 09:18	Anonymous (not verified)	76.76.239.60	belilove company of Iowa Inc	Limited Liability Company	601 south 23rd street Fairfield Iowa 52556	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-09-20	James Belilove	jimb@cec-waterjet.com	Fairfield	Jefferson	Iowa	James thompson	ellen bowen	Signed	(1) The employer does not elect the employers’ liability coverage.	James Belilove	jimb@cec-waterjet.com	Owner and president	Fairfield	Jefferson	Iowa	James Thompson	Ellen Bowen	Signed
381	2021-02-02 12:46	Anonymous (not verified)	167.142.150.21	T and A Transfer, LLC.	Limited Liability Company	3330 340th St	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-02-02	Todd L Ahrenholtz	todd.ahrenholtz123@gmail.com	Manilla	IA	IA	Angela Ahrenholtz	Angela Ahrenholtz	Signed	(1) The employer does not elect the employers’ liability coverage.	Todd L Ahrenholtz	todd.ahrenholtz123@gmail.com	owner	Manilla	Iowa	Iowa	Angela Ahrenholtz	Angela Ahrenholtz	Signed
493	2021-04-22 08:54	Anonymous (not verified)	66.188.136.150	Frank Lantz	Proprietorship	609 Clinton Street, Charles City, IA 50616	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-04-21	Frank Lentz	kschumacher@tricorinsurance.com	Charles City	Floyd	IA	Shuree Behr	Mitch Kemp	Signed	(1) The employer does not elect the employers’ liability coverage.	Frank Lantz	kschumacher@tricorinsurance.com	Same	Charles City	Floyd	IA	Shuree Behr	Mitch Kemp	Signed
605	2021-08-16 16:06	Anonymous (not verified)	67.55.155.46	COMPLETE CONSTRUCTION SERVICES LLC	Limited Liability Company	718 FOX RUN	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2021-08-16	DAVID BOWER	BOWERD@OSKYCSD.ORG	OSKALOOSA	MAHASKA	IOWA	JAMES MCNAUL	CINDY STEVENSON GRUBB	Signed	(1) The employer does not elect the employers’ liability coverage.	DAVID BOWER	BOWERD@OSKYCSD.ORG	PRESIDENT	OSKALOOSA	MAHASKA	IOWA	JAMES MCNAUL	CINDY STEVENSON GRUBB	Signed
717	2021-11-05 13:32	Anonymous (not verified)	209.252.172.87	Nick Wiles CW Flooring LLC	Limited Liability Company	Po Box 445, 710 6th St Wellman, IA 52356	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2020-06-24	Nick Wiles CW Flooring LLC	nickwiles007@gmail.com	Wellman	Washington	Iowa	Heather Howell	Sarah Coberley	Signed	(1) The employer does not elect the employers’ liability coverage.	Nick Wiles CW Flooring LLC	nickwiles007@gmail.com	Self Employed	Wellman	Washington	Iowa	Sarah Coberley	Heather Howell	Signed
924	2022-02-17 13:02	Anonymous (not verified)	208.81.192.69	Wapsie Valley Construction, LLC	Limited Liability Company	1154 Dennison Ave., Fairbank, IA 50629	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-02-17	Henry O. Miller	accounting@robertseddy.com	Fairbank	Buchanan	Iowa	Brian C. Eddy	Samantha J. Stelter	Signed	(1) The employer does not elect the employers’ liability coverage.	Merle Miller	accounting@robertseddy.com	Same person	Fairbank	Buchanan	Iowa	Brian C. Eddy	Samantha J. Stelter	Signed
1867	2023-10-16 12:34	Anonymous (not verified)	94.188.205.176	North Bay Dock Service	Proprietorship	PO Box 374, Spirit Lake, IA 51360	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2023-10-16	Donald L. Johnson, Jr.	djtjaj@outlook.com	Spirit Lake	Dickinson	Iowa	Michael Chozen	April Bosma	Signed	(1) The employer does not elect the employers’ liability coverage.	Teresa Johnson	djtjaj@outlook.com	bookkeeper	Spirit Lake	Dickinson	Iowa	Michael Chozen	April Bosma	Signed
829	2022-01-11 11:03	Anonymous (not verified)	173.22.78.156	Marr Arnold Planning, LLC	Limited Liability Company	1328 California Ave, Ames, IA 50014	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-01-11	Summer Marr	summer@marrarnoldplanning.com	Ames	Story	IA	Beth Skluzacek	Kris Evans	Signed	(1) The employer does not elect the employers’ liability coverage.	Summer Marr	summer@marrarnoldplanning.com	owner	Ames	Story	IA	Beth Skluzacek	Kris Evans	Signed
1036	2022-04-06 10:22	Anonymous (not verified)	67.212.111.166	Precision Painting	Proprietorship	507 Broad Street, Reinbeck Iowa 50669	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-04-06	Dan Bowser	dbowser.precision.painting@gmail.com	Reinbeck	IA	United States	Kari Houle	Steve Swanson	Signed	(1) The employer does not elect the employers’ liability coverage.	Cory Koger	coryspainting@gmail.com	Self	CEDAR FALLS	IA	United States	Kari Houle	Steve Swanson	Signed
1979	2024-01-08 14:59	Anonymous (not verified)	94.188.205.167	Nathan Troendle	Proprietorship	Lansing Iowa	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-01-05	Nathan Troendle	darrele@ciains.biz	Lansing	Allamakee	Iowa	Chris Fye	Darrel Elsbernd	Signed	(1) The employer does not elect the employers’ liability coverage.	Nathan Troendle	darrele@ciains.biz	self	Lansing	Allamakee	Iowa	Chris Fye	Darrel Elsbernd	Signed
1148	2022-06-08 11:41	Anonymous (not verified)	70.96.153.153	Brody Willet LLC	Limited Liability Company	244 #rd Ave N, Alburnett, IA 52202	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-06-08	Brody Willet	brody@optionsexteriors.com	Alburnett	Linn County	Iowa	Charlotte Rasmussen	Austin Miller	Signed	(1) The employer does not elect the employers’ liability coverage.	Brody Willet	brody@optionsexteriors.com	Owner	Alburnett	Linn County	Iowa	Charlotte Rasmussen	Austin Miller	Signed
2091	2024-03-12 15:23	Anonymous (not verified)	94.188.205.166	Shelley onnen	Proprietorship	1319 West 2nd Street	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-03-12	Shelley L Onnen	Shelleyonnen47@gmail.com	PERRY	IA	United States	Matthew Dean Rote	Jerica Renae Wiborg	Signed	(1) The employer does not elect the employers’ liability coverage.	Shelley L Onnen	Shelleyonnen47@gmail.com	Self	PERRY	IA	United States	Matthew Dean Rote	Jerica Renae Wiborg	Signed
1260	2022-08-16 11:30	Anonymous (not verified)	173.29.47.222	Premiere Plastering & Drywall, Inc.	Proprietorship	2331 W. 63rd St., Davenport, IA 52806	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(2) I am electing the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	2022-08-16	Jacob Dreifurst	j_dreifurst@yahoo.com	Colona	Henry	Illinois	Jamie Wardlow	Kandra Blumenshein	Signed	(2) The employer elects the employers’ liability coverage by purchasing valid workers’ compensation insurance specifically including me.	Premiere Plastering & Drywall, Inc.	premiere_pd_llc@yahoo.com	Subcontractor	Davenport	Iowa	United States	Jamie Wardlow	Kandra Blumenshein	Signed
2203	2024-05-06 12:44	Anonymous (not verified)	94.188.207.228	Cma landimprovments	Limited Liability Company	530 50th pleasantville	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2024-05-06	Cody authier	cauthier85@gmail.com	Pleasantville	Marion	Iowa	Melissa authier	Valerie vanhelten	Signed	(1) The employer does not elect the employers’ liability coverage.	Cody authier	cauthier85@gmail.com	Self	Pleasantville	Marion	Iowa	Melissa authier	Valerie vanhelten	Signed
1372	2022-11-14 20:36	Anonymous (not verified)	198.14.213.147	Accurate Grading, LLC	Limited Liability Company	1417 290th St Macksburg, IA 50155	I acknowledge that I am a proprietor, limited liability company member, limited liability partner, or partner and that I am not required to be covered by the workers’ compensation law of this state pursuant to section 85.1A. I understand that by signing this statement I am not electing the coverage of chapters 85, 85A, and 85B of the Code of Iowa relating to workers’ compensation.	I understand that my nonelection of the coverage of chapters 85, 85A, and 85B is not a waiver of any rights or remedies available to me or to others on my behalf in a civil action related to personal injuries sustained by me arising out of and in the course of employment with the employer.	I also understand that by signing this statement and checking alternative (1) below I am not electing employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	I also understand that the signing of this statement and checking of alternative (1), under "Agreement by Employer," below by an authorized agent of the employer is a nonelection for the employer of the employers’ liability coverage for bodily injuries or death sustained by me arising out of and in the course of my employment with the employer.	(1) I am not electing the employers’ liability coverage.	2022-11-14	Dustin A McVay	dustin0980@gmail.com	Macksburg	IA	United States	Dustin A McVay	Angela D McVay	Signed	(1) The employer does not elect the employers’ liability coverage.	Dustin A McVay	dustin0980@gmail.com	Owner	Macksburg	United States	Iowa	Dustin A McVay	Angela D McVay	Signed